Provider Demographics
NPI:1053577452
Name:BERTIE COUNTY RURAL HEALTH ASSOCIATION
Entity type:Organization
Organization Name:BERTIE COUNTY RURAL HEALTH ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAVONDA
Authorized Official - Middle Name:H
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-794-1835
Mailing Address - Street 1:104 RHODES AVE
Mailing Address - Street 2:PO BOX 628
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983-9656
Mailing Address - Country:US
Mailing Address - Phone:252-794-3042
Mailing Address - Fax:252-794-2911
Practice Address - Street 1:104 RHODES AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-9656
Practice Address - Country:US
Practice Address - Phone:252-794-3042
Practice Address - Fax:252-794-2911
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BERTIE COUNTY RURAL HEALTH ASSOC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-05
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344512CMedicaid